Provider Demographics
NPI:1417491374
Name:SHAH, KARAN
Entity Type:Individual
Prefix:
First Name:KARAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7965
Mailing Address - Country:US
Mailing Address - Phone:408-386-7695
Mailing Address - Fax:
Practice Address - Street 1:3909 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7965
Practice Address - Country:US
Practice Address - Phone:608-788-9700
Practice Address - Fax:608-788-9706
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75895183500000X
WI21314-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist